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Wednesday, May 22, 2013
Fertility and Miscarriage
I am a healthy 26 year old woman. I have never had any kind of reproductive problems or infections. My husband and I had been married two years before I finally conceived the first time. It ended in miscarriage at seven weeks. It was passed off as a one time thing and I was told to wait three months and try again. A year later, I conceived again. Again, it ended in miscarriage at seven weeks. My doctor did some hormone testing and said my progesterone was low. He put me on Clomid and Prometrium. After a year-I only took the Clomid three months at a time-I still hadn`t conceived so he doubled the dose. I conceived the first month and it ended in miscarriage at seven weeks.
I have tried using ovulation kits, but they are always negative, even when I was on the Clomid. I know I am ovulating because I am getting pregnant which show up in ultrasound. Also, when I use home pregnancy tests, even as late as six weeks, they are always negative. However, a blood test shows positive. Because of this, my doctor still thinks it is hormonal.
I go back in a couple of months and he wants to do another round of hormone tests and test for some antibodies. Do you have any idea what can be causing this or any other suggestions or questions I should have for my doctor?
Strictly speaking, the problem is of recurrent pregnancy losses rather than infertility, the inability to conceive. The causes for these two problems are different so are important to differentiate.
There are many theories of why women will have recurrent pregnancy loss and there is much more speculation than fact of how to treat these conditions. I will try to outline the causes and you can then use them to discuss diagnosis and treatment with your doctor.
Some couples will have subtle chromosomal defects that, even though the couple are normal, can cause chromosomal problems in their offspring that prevent development. This can be tested by doing genetic analysis on the miscarried pregnancy tissue or by genetic testing of both parents. Treatment depends on the chromosomal issue that is found.
2) Structural Changes of the uterus
Some women will have anatomic changes of the lining of the uterus that disturb the pregnancy once it occurs. These changes include certain types of uterine fibroids and changes present since birth (uterine didelphys or bicornuate uterus). These changes can be diagnosed with special imaging studies or hysteroscopy.
The classic hormonal cause of early pregnancy loss is a luteal-phase defect. This is the inability of the ovary to produce sufficient progesterone to maintain the pregnancy during the first 11 or 12 weeks of the pregnancy. Luteal phase defects are uncommon and are treated by giving progesterone in early pregnancy.
This is the aspect of recurrent pregnancy loss that is the most controversial. There are clearly instances where antibodies are present in the mother that can cause pregnancy loss. Some of the more notable antibodies are anti-cardiolipin antibody (ACA) and Lupis anti-coagulant (LAC). There are many others.
The controversy arises because there are many women with these antibodies that encounter no problems with miscarriage. It is also difficult to measure these antibodies with different labs around the country giving very different results.
Arthur T Ollendorff, MD
Associate Professor of Obstetrics and Gynecology
College of Medicine
University of Cincinnati